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11 <br />• <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />HAZARDOUS WASTE TANK CLOSURE CERTIFICATION <br />I. FACILITY IDENTIFICATION <br />BUSINESS NXVE tum r FAt uTY rmsma Dm- Do" Bmimss M) ]FACILITY <br />IDN <br />ao <br />TANK OWNER NAME <br />E ACO .JG <br />a <br />TANK OWNER ADDRESS <br />a o l v L�n1 f// Tc 300 _ <br />/ <br />TANK OWNER CITY —'?� ]n STATE /L L/N / S ZIP CODE <br />H. TANK CLOSURE INFORMATION <br />Tank ID N Concentration of Flammable Vapor Concentration of Oxygen <br />(Awdraddimndoopir <br />ofm'spyer..t1m Top <br />u.a robs <br />Center <br />Bottom Top <br />Center <br />Botrom <br />TANK <br />ATINTERIORMOSPHERE <br />1 5 5� ].e. <br />c;_, <br />].de 20 ]nn <br />20 <br />,s]6 <br />2C2 747c <br />READINGS <br />Z "50 /f! 74% <br />,.96 <br />74� <br />62 O ]Soo <br />1 n ,506 <br />-2 D ]i« <br />B // S��St S ]aL <br />,am <br />75' <br />5 ]5]e -o ]51. <br />Zo ,aJ6 <br />o ,Slc <br />2-0 <br />HL CERTIFICATION <br />On examination of the tank, l certify the tank is visually free from product, sludge, scale (thin, Flaky residual of tank contents), rinseate and debris. 1 further certify that <br />the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURESTATUS <br />OR AFFILIATION OF CERTIFYING PERSON <br />Certifier is a tepresenative of the CUPA, authorized agency, or LIA: ]to <br />❑Yea ANo <br />N OF RTIFTE (Pring ]� <br />/� No/2 t <br />Nasse of CUPA, audsoded agency, or LIA,as <br />: <br />TELE OF CERTIFIER M <br />If certifier is other than CUPA/ LIA check appropriate box below: 762 <br />a. Certified Industrial Hygienist (CDs <br />x <br />ADDRESS❑ <br />Q 5 <br />❑ b. Certified Safety Professional (CSF) <br />❑ c. Certified Marine Chemist (CMC) <br />CITY ,n <br />GCA. j / <br />❑ d. Registered Environmental Health Specialist (REHS) <br />❑ e. Professional Engssscr(PE) <br />PHONE ]sa <br />O S <br />❑ E Class II Registered Enwrostmenal Assessor <br />S. Contractors' State License Board licensed contractor (with hazardous <br />substance removal certification) <br />759 <br />DATE <br />CERTIFFIICCATION TIMEd <br />,5l <br />TAA PREY SLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS <br />Irae ms imnr rmnplmeshall be n Wclod wilhacrnMmbtegr Wkshoprrr m w Icm mgrsWra to mt) . Yes (3 No <br />CERTIFIER'S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER, DISPOSAL FACILITY, ETC: ]� <br />✓e,,,iFt) <br />T1/1'1/Z/.tls&F- art-aCs ��PP�D �,av <br />A copy of this cerulea shall attmipmY the =it to the recycling/ disposal facility and le Provided b the CUPA If thee ism CUPA, copies shW be submhtrA to the LIA sad authorized <br />AR awnr/a for of the Looks tem removal cantor, and the recycli., I dilmul llilfty. <br />UPCF (12/99) 39 Formerly DTSC 1249 (6/98) <br />